National Subcutaneous Insulin Form Pilot NSW Health Version

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A national pilot project supported by the

Australian Commission on Safety and Quality in Health Care

Background

• Insulin recognised internationally as a high risk medicine

• Standardised Insulin prescribing and administration forms for adults have been implemented in Queensland Health hospitals since 2008

• Need has been established for a nationally standardised form to accompany the National Inpatient Medication Chart (NIMC)

Monitoring

Insulin Administration

Insulin Orders

Communication and Safety

Cross reference the insulin form on the NIMC

• Also cross reference in regular medication order to ensure that:– staff refer to the Insulin Subcutaneous Order – insulin is not omitted from discharge medications.

• A sticker is available

or

Before you start

Patient Identification

• Affix the current patient identification label (with the patient’s name printed underneath)

OR • As a minimum, the patient’s name, UR number,

address, date of birth and gender written in legible print

Hospital Demographics

• Complete Facility, Year and Ward / Unit

Monitoring / Notification Instructions

• Prescriber indicates the BGL Frequency of monitoring required

• Default BGL monitoring for inpatients is Pre-meals and at 21:00hrs

• Consider more frequent BGL monitoring if required

Medical Officer to notify / Special Instructions

The prescriber should document:– who to notify of out of range BGLs or other

diabetes related concerns– any Special Instructions

If no contact name is written, the treating prescriber or team will be notified

– After hours the doctor on-call will be notified

Diabetes treatment prior to admission

• The prescriber, pharmacist or nurse writes the Diabetes treatment prior to admission in the space provided– may include oral diabetes medicines and/or

insulin types and doses– optional additional information may include

the insulin device that the patient was using

Blood Glucose Level (BGL) Monitoring Section

• Write the Date at the top of the day’s column• Write the patient’s Diet

– This prompts for re-assessment of insulin requirements should the patient be fasting for a procedure or be on a diet such as clear fluids

BGL Monitoring Section• Write the Time the BGL is measured• Perform a BGL according to facility procedure• Write the BGL in the coloured row corresponding

to the relevant BGL range • Note and act on any ALERT instructions in the

BGL ranges

ALERTS (1)

If the BGL is less than 4 mmol/L• Initiate hypoglycaemia management

(see page 4 of chart) • Notify the treating doctor or doctor on-

call• Tick the Hypo Intervention and

Dr Notified boxes• Perform follow up BGLs and respond

accordingly • Document treatment and response on

form and in medical record

ALERTS (2)High ALERT ranges are:•BGL greater than 20 mmol/L •second consecutive BGL greater than 16 mmol/L•third consecutive BGL greater than 12 mmol/LIf BGL is in one of the ALERT ranges:•Notify the treating prescriber or doctor on-call

– Perform a ketone test (urine or blood), document result in the Ketones box

– Document the actions taken in the medical record

•Tick the Dr Notified box

Insulin Orders (Prescribing)• A patient may be prescribed any combination of

Routine, Supplemental, and Stat / Phone Insulin Orders

• If a patient with diabetes is not receiving subcutaneous insulin, this form should still be used for BGL monitoring

Routine Insulin Orders (1)

• Six (6) spaces to prescribe routine insulin– Four (4) spaces with Meal / time pre-printed

• Breakfast• Lunch• Dinner• Pre-Bed

• Use additional sections when a patient requires 2 insulin types at a single meal / time

–Two (2) additional spaces without the pre-printed Meal / time

Routine Insulin Orders (2)The prescriber must: • Write the type of insulin (full trade name) e.g.Mixtard 30/70• Sign each order • Print their name in full at least once

on the form• Write the date • Write the dose as a whole number

– Units is pre printed as a watermark• Initials each dose ordered

– initials is pre printed as watermark• Insulin doses must be ordered for each day• It is usually appropriate to also order doses for the

following morning

Routine Insulin Orders (3)

• The prescriber should also write the full trade name of insulin type/s in the Administration Record e.g.Mixtard 30/70

Routine Insulin Orders (4)

If routine insulin is ceased, the prescriber must:• Draw a line through the order

– Do not obliterate the order

• Write the reason for ceasingthe order, the date the order was ceased and initials

• When the insulin regimen is being changed, write the new order on a new form

Ceased. Changing to mixed insulin prior to discharge. See new chart

Supplemental Insulin Orders (1) • It is not necessary to prescribe

supplemental insulin for all patients• It might be considered for erratic

BGLs where strict control is required• Patients may require supplemental

insulin if:– their condition, dietary intake or

concurrent medications are altering insulin requirements

– optimal doses not yet determined

• May be in addition to a routine mealtime or basal insulin dose

Supplemental Insulin Orders (2)Prescribing • Tick the appropriate Frequency• Write the Name of insulin, start date and start time• Standardised BGL ranges are pre printed

– if required, different BGL ranges may be used• Write insulin doses

– suggested doses available in Table 1 (page 1)• Supplemental order remains valid until

changed or ceased • Sign and initial the order • Review supplemental doses as required • Changes are validated by initialling

changes in the corresponding column• Also write the Name of supplemental

insulin in the Administration Record

Stat / Phone Orders (1)

Stat Orders• Document any single dose orders in this section• The prescriber must verbally inform the nurse responsible

for the patient’s care of any stat orders

Phone Orders• For Phone Orders nurses document:

– the Date the order is received– the Name of insulin– the dose (as a whole number)– Date / time the dose is to be administered– ‘phone order’ and the name of prescriber– the initials of the nurses who received the order

• A second nurse must read back the written order to the doctor to confirm and then countersign the phone order

• The nurses receiving the phone order must check to see if the stat / phone order replaces, or is in addition to, other insulin orders

• Phone orders should be signed by the prescriber within 24 hours• The nurse also cross references the phone order in the Routine Insulin

Orders

Stat / Phone Orders (2)

Insulin Administration

• If clinical judgement indicates that a prescribed dose should not be administered, notify the prescriber or on-call doctor to review

• Write the code W for withheld and document the reason and the action taken in the clinical record

Administering Routine Insulin

• Mealtime insulin doses are given immediately before the patient eats • Contact prescriber or doctor on-call if the patient has been receiving insulin

and there is not a dose ordered for a meal / time • Calculate, prepare, check and administer dose in line with facility procedure• Document the time given • Document the dose administered in the row against the correct Name of

routine insulin row in the Administration Record• Initial to acknowledge administering the dose• Patients may have additional orders for the same time - check for

Supplemental and Stat / Phone insulin orders• Example next slide

Administering Supplemental Insulin

• Review supplemental insulin order and current BGL to determine if supplemental dose is required

• Calculate total insulin dose required – May be in addition to routine insulin dose

• Prepare, check and administer total insulin dose • Document the time given• Document the doses or routine and supplemental insulin

separately in the Administration Record• Initial to acknowledge administration of the dose• Example next slide

Administering Stat/ Phone Orders

• Prepare, check and administer dose • Document the time given • Document the dose of stat / phone insulin

administered in the row against the corresponding name of Routine insulin

• Sign as having administered the dose• Cross reference phone orders in the Routine

Insulin Orders section • Example next slide

Comments Section• For documenting communication between

members of the treating team with regard to insulin therapy and diabetes management

• Examples of what to document here include:– Doctor has been notified of the BGL– hypoglycaemic event has been treated– patient changed to intravenous insulin.

Pharmacy Review

• The clinician undertaking the pharmacy review will sign this section as a record that they have reviewed the insulin form (on the corresponding day) to ensure that all insulin orders are clear, safe and appropriate for that individual patient, reducing the risk of an adverse drug event

Guidelines for Managing Hyperglycaemia Alerts

To assist inexperienced and non specialist clinicians with management of hyperglycaemia in hospital inpatients. They provide information related to:

assessment required when called for a Hyperglycaemia Alert

initiation of basal and mealtime insulin and adjustment of insulin doses

suggested stat and supplemental doses based on weight or previous total daily dose.

1

2

3

Management of Hypoglycaemia in Diabetes - Adult

• Has four treatment pathways:– conscious and cooperative– insulin infusion– nil by mouth or nil by tube– oral or tube fed

• Appropriate food choices are listed– Food choices should be centrally located

in each ward / unit / outpatient facility– Each unit should have access to glucose

50% intravenous 50mL and glucagon 1mg injection to use in emergency situations

– Glucose based products are preferred as initial treatment

– Non diet products must be used to treat hypoglycaemia

Larger example next slide

Management of Hypoglycaemia in Diabetes - Adult

Diabetes treatment review after hypoglycaemia

• Below the flowchart are guidelines for Diabetes treatment review following treated hypoglycaemia

• Diabetes management must be reviewed in response to a hypoglycaemic event

Acknowledgement This work was developed by Medication Services Queensland of Queensland Health and is based on the user guide developed to support the State Insulin Subcutaneous Order and Blood Glucose

Record for adults.